By Counterforce Health Team in Pomalyst (pomalidomide) —

How to Get Pomalyst (Pomalidomide) Covered by UnitedHealthcare in Florida: Coding, Appeals, and REMS Requirements

Answer Box: Getting Pomalyst Covered by UnitedHealthcare in Florida

UnitedHealthcare requires prior authorization for Pomalyst (pomalidomide) with specific documentation: C90.02 (multiple myeloma in relapse) ICD-10 code, proof of prior lenalidomide and proteasome inhibitor failure, and PS-Pomalidomide REMS enrollment. Submit via the UHC Provider Portal with pathology reports, treatment history, and signed REMS Patient-Physician Agreement. If denied, you have 180 days for internal appeals and external review rights through Florida's Department of Financial Services.

First step today: Contact your oncologist to confirm REMS certification and gather prior therapy documentation while your clinic prepares the UnitedHealthcare PA form.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for Multiple Myeloma
  3. Product Coding: NDC, Units, and Billing
  4. Clean Request Anatomy
  5. Frequent Coding Pitfalls
  6. Verification with UnitedHealthcare
  7. Pre-Submission Audit Checklist
  8. Appeals Process for Florida
  9. REMS Program Requirements
  10. Cost-Saving Options

Coding Basics: Medical vs. Pharmacy Benefit

Pomalyst (pomalidomide) is classified as an oral specialty drug under pharmacy benefit, not medical benefit. This means it's billed through pharmacy claims using NDC codes, not HCPCS J-codes typically reserved for infused medications.

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all indications UHC PA Policy
Formulary Status Specialty tier with quantity limits UHC Provider Portal
REMS Enrollment Mandatory for all patients PS-Pomalidomide REMS
Benefit Channel Pharmacy (Part D for Medicare) UHC Policy Documents
Step Therapy No explicit requirements UHC PA Criteria

ICD-10 Mapping for Multiple Myeloma

The primary ICD-10 code for relapsed/refractory multiple myeloma is C90.02 (Multiple myeloma in relapse). This billable code is confirmed in the 2026 edition by CMS and applies to most Pomalyst authorizations.

Key Multiple Myeloma Codes

Status ICD-10 Code Description When to Use
Initial/Refractory C90.00 Not in remission Newly diagnosed or primary refractory
Remission C90.01 In remission Post-treatment response
Relapsed C90.02 In relapse Disease recurrence after prior response

Documentation Requirements

Your oncologist must document:

  • Relapse criteria: ≥25% increase in M-protein or other IMWG progression markers
  • Prior therapy details: Specific lenalidomide and proteasome inhibitor regimens, duration, and failure dates
  • Current disease status: Labs (SPEP/UPEP, free light chains), imaging, bone marrow results
Tip: Use supporting Z-codes like Z92.21 (personal history of antineoplastic chemotherapy) to strengthen the prior therapy documentation.

Product Coding: NDC, Units, and Billing

Pomalyst has no standard HCPCS J-code because it's an oral medication. Billing uses the 11-digit NDC number specific to each strength and package size.

NDC and Units Structure

  • Billing unit: 1 unit = 1 capsule (regardless of mg strength)
  • Common strengths: 1mg, 2mg, 3mg, 4mg capsules
  • Standard cycle: 21 capsules for 28-day cycle (Days 1-21 on therapy, Days 22-28 off)
  • Days supply: Usually 21 or 28 days depending on payer policy

Example Billing Line

Product ID: [11-digit NDC from package]
Quantity: 21 (capsules)
Days Supply: 21
ICD-10: C90.02
PA Number: [UHC approval number]
Note: Exact NDC numbers change with manufacturer packaging. Always use the NDC from the actual dispensed product or verify with BMS Access Support.

Clean Request Anatomy

A successful UnitedHealthcare prior authorization includes these elements:

Required Documentation Package

  1. Completed UHC Pomalyst PA Form with:
    • Patient demographics and insurance information
    • Diagnosis (multiple myeloma) with ICD-10 code C90.02
    • Requested regimen: Pomalyst + dexamethasone dosing schedule
  2. Clinical Evidence:
    • Pathology report confirming multiple myeloma diagnosis
    • Recent labs and imaging showing relapsed disease
    • Comprehensive prior therapy timeline including lenalidomide and proteasome inhibitor exposure
  3. REMS Compliance Documentation:
    • Signed PS-Pomalidomide REMS Patient-Physician Agreement
    • Confirmation of prescriber and pharmacy REMS certification
    • Pregnancy testing/contraception plan documentation
  4. Medical Necessity Letter citing:
    • NCCN Guidelines support for Pomalyst in this line of therapy
    • Why alternative treatments are inappropriate
    • Clinical rationale for combination with dexamethasone

Frequent Coding Pitfalls

Common Mistakes to Avoid

  • Wrong benefit channel: Submitting under medical benefit instead of pharmacy
  • Missing PA approval: Billing without obtaining UHC prior authorization
  • Incorrect units: Using mg-based units instead of capsule count
  • REMS non-compliance: Dispensing through non-certified pharmacy
  • Incomplete documentation: Missing prior therapy failure evidence

Unit Conversion Errors

Pomalyst is always billed by capsule count, not milligrams. A 21-day supply of 4mg daily = 21 units (capsules), not 84 units (total mg).

Verification with UnitedHealthcare

Before submitting your prior authorization:

  1. Check Provider Portal: Verify current PA requirements at the UHC Provider Portal
  2. Confirm Pharmacy Network: Ensure dispensing pharmacy is UHC-contracted and REMS-certified
  3. Validate Codes: Cross-reference ICD-10 and NDC with current UHC policies
  4. Review Formulary: Check if Pomalyst tier or coverage has changed

UnitedHealthcare PA Submission Options

  • Online: UHC Provider Portal (fastest processing)
  • Phone: 866-889-8054 for PA submissions
  • Fax: Use number provided in denial letter (varies by plan)

Pre-Submission Audit Checklist

Clinical Documentation

  • C90.02 ICD-10 code documented with supporting labs/imaging
  • Prior lenalidomide therapy with dates and reason for discontinuation
  • Prior proteasome inhibitor therapy with outcomes
  • Current disease status confirming relapse/progression

REMS Compliance

  • Prescriber enrolled in PS-Pomalidomide REMS program
  • Patient signed REMS Patient-Physician Agreement
  • Dispensing pharmacy REMS-certified
  • Pregnancy testing/contraception documented (if applicable)

Administrative

  • Correct UHC PA form completed
  • Medical necessity letter with NCCN references
  • All supporting documents attached
  • Submission via preferred UHC channel

Appeals Process for Florida

If UnitedHealthcare denies your Pomalyst prior authorization, Florida law provides multiple appeal levels:

Internal Appeals (UnitedHealthcare)

Step 1: Peer-to-Peer Review

  • Request within 24 hours of denial
  • Your oncologist speaks directly with UHC medical director
  • Provide missing clinical details and guideline support

Step 2: Formal Internal Appeal

  • File within 180 days of denial
  • Submit via UHC Provider Portal with additional evidence
  • Decision typically within 30 days (expedited: 72 hours for urgent cases)

External Review (Florida)

After exhausting UHC internal appeals:

  • Timeline: Request within 4 months of final internal denial
  • Process: File through Florida Department of Financial Services
  • Cost: No charge to consumer
  • Success rate: 20-50% overturn rate for oncology drugs with strong documentation

Florida Insurance Consumer Helpline: 877-693-5236

From our advocates: We've seen Pomalyst appeals succeed when oncologists provide detailed NCCN guideline citations and emphasize that delays could compromise treatment outcomes. The key is demonstrating that prior therapies truly failed and alternatives aren't clinically appropriate.

REMS Program Requirements

The PS-Pomalidomide REMS program is mandatory for all Pomalyst patients due to embryo-fetal toxicity risks.

Key REMS Elements

Prescriber Requirements:

  • Complete REMS certification training
  • Counsel patients on embryo-fetal risks
  • Maintain signed Patient-Physician Agreement forms

Patient Requirements:

  • Enroll in REMS program before first dose
  • Complete monthly safety surveys
  • Comply with pregnancy testing and contraception (if applicable)

Pharmacy Requirements:

  • REMS certification for dispensing
  • Verify patient REMS enrollment before each fill
  • Maintain REMS documentation

For REMS enrollment and support, contact BMS REMS Patient Safety or call 1-888-423-5436.

Cost-Saving Options

Pomalyst's retail cost often exceeds $23,000 per cycle, but several assistance programs can reduce patient costs:

Manufacturer Support

  • BMS Access Support: Coverage verification, PA assistance, and copay cards
  • Commercial copay assistance: Many patients pay ≤$50/month
  • Free drug programs: For qualifying uninsured/underinsured patients

Medicare-Specific (2025)

  • $2,000 annual out-of-pocket cap: 100% coverage after reaching limit
  • Medicare Prescription Payment Plan: Spread costs over 12 months
  • Low-Income Subsidy (Extra Help): May reduce costs to $0

Foundation Grants

  • Patient Advocate Foundation
  • Leukemia & Lymphoma Society
  • Multiple Myeloma Research Foundation

Counterforce Health helps patients navigate these complex coverage challenges by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and creates point-by-point rebuttals aligned with payer policies, significantly improving approval rates for specialty medications like Pomalyst.

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take for Pomalyst? Standard PA decisions typically take 3-5 business days. Urgent cases may be expedited to 24-72 hours with proper clinical justification.

What if Pomalyst isn't on my UnitedHealthcare formulary? Most UHC plans cover Pomalyst on specialty tiers. If non-formulary, request a formulary exception with medical necessity documentation and NCCN guideline support.

Can I appeal if I live in Florida but have an employer plan? Yes, but ERISA plans follow federal appeal rules rather than Florida state requirements. The process is similar but may have different timelines and external review procedures.

Does step therapy apply to Pomalyst with UnitedHealthcare? UHC's current policy doesn't mandate specific step therapy, but requires documented failure or contraindication to listed alternatives including lenalidomide and proteasome inhibitors.

What happens if my REMS enrollment lapses? Pharmacies cannot dispense Pomalyst without active REMS enrollment. Contact BMS REMS Patient Safety immediately to reactivate your enrollment and avoid treatment delays.

How do I find a REMS-certified pharmacy in Florida? Use the pharmacy locator at BMS REMS Patient Safety or ask your oncology team for their preferred REMS-certified specialty pharmacy partners.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may vary by plan and change over time. Always consult with your healthcare provider and insurance plan for the most current information. For assistance with complex coverage issues, organizations like Counterforce Health specialize in helping patients navigate prior authorization and appeal processes.

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